Low incidence of hepatitis C virus among prisoners in Scotland

Mixed-methods evaluation of point-of-care hepatitis C virus RNA testing in a Scottish prison

OBJECTIVES

Hepatitis C virus (HCV) poses a global public health threat. Prisons are a focus of prevention efforts due to high infection burdens. Expedition of treatment for incarcerated people is critical, as many are short-term sentenced. We evaluated point-of-care (PoC) HCV RNA testing in a maximum-security Scottish prison and assessed its impact on transition to treatment. We also evaluated costs and determinants of implementation.

DESIGN

Mixed-methods evaluation of a single-centre care pathway pilot using National Health Service (NHS) data from 2018 to 2021. Descriptive statistics and survival analysis were undertaken. Cost analysis was assessed from a provider perspective. Healthcare staff participated in semistructured interviews and thematic analysis with a deductive approach was undertaken to identify implementation determinants.

SETTING

A large maximum-security Scottish prison health centre administered by the NHS.

PARTICIPANTS

296 incarcerated NHS patients (all men) and six NHS staff members (two men and four women).

INTERVENTIONS

HCV testing using the Cepheid GeneXpert platform with Xpert HCV VL Fingerstick assay.

OUTCOME MEASURES

The main outcome was survival (in days) from HCV test to treatment initiation. Secondary outcomes were cost-per-cure obtained and implementation determinants.

RESULTS

During the pilot, 167 Xpert tests were administered, with an 84% completion rate, and treatment transition was superior for those who received it (p=0.014). Where PoC tests were administered, shorter survival to treatment was observed (19 vs 33 days: adjusted HR (aHR) 1.91 (1.03-3.55), p=0.040; 19 vs 50 days; aHR 3.76 (1.67-8.46), p=0.001). PoC was costlier than conventional testing. In qualitative analysis, most facilitators were observed among characteristics of individual domain while most barriers were noted in the inner setting.

CONCLUSIONS

Integrating PoC HCV RNA diagnosis into nurse-led HCV care in a maximum-security prison health centre shortens survival to HCV treatment. However, there are cost implications to this approach and multiple determinants that impact on implementation should be addressed.

Hepatitis C prevalence in incarcerated settings between 2013–2021: a systematic review and meta-analysis

Background

The introduction of highly effective direct-acting antiviral therapy has changed the hepatitis C virus (HCV) treatment paradigm. However, a recent update on HCV epidemiology in incarcerated settings is necessary to accurately determine the extent of the problem, provide information to policymakers and public healthcare, and meet the World Health Organization's goals by 2030. This systematic review and meta-analysis were performed to determine the prevalence of HCV Ab and RNA in incarcerated settings.

Methods

For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and Web of Science for papers published between January 2013 and August 2021. We included studies with information on the prevalence of HCV Ab or RNA in incarcerated settings. A random-effects meta-analysis was done to calculate the pooled prevalence and meta-regression to explore heterogeneity.

Results

Ninety-two unique sources reporting data for 36 countries were included. The estimated prevalence of HCV Ab ranged from 0.3% to 74.4%. HCV RNA prevalence (available in 46 sources) ranged from 0% to 56.3%. Genotypes (available in 19 sources) 1(a) and 3 were most frequently reported in incarcerated settings. HCV/HIV coinfection (available in 36 sources) was highest in Italy, Estonia, Pakistan, and Spain. Statistical analysis revealed that almost all observed heterogeneity reflects real differences in prevalence between studies, considering I² was very high in the meta-analysis.

Conclusions

HCV in incarcerated settings is still a significant problem with a higher prevalence than in the general population. It is of utmost importance to start screening for HCV (Ab and RNA) in incarcerated settings to give clear, reliable and recent figures to plan further treatment. This is all in the context of meeting the 2030 WHO targets which are only less than a decade away.

Trial registration

PROSPERO: CRD42020162616

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14623-6.

Global prevalence of hepatitis C in prisoners: a comprehensive systematic review and meta-analysis

Hepatitis C virus (HCV), one of the most significant causes of liver inflammation, has a high annual mortality rate. The unfavorable hygiene conditions and inadequate health monitoring in many prisons increase the risk of blood-borne infections such as hepatitis C. The growing incidence of this disease among prisoners results in overspill transmission to the general population from undiagnosed prisoners that have been released. Therefore, the aim of this study was to investigate the prevalence of hepatitis C among the world's prison population. A systematic review and meta-analysis of studies on the prevalence of hepatitis C was carried out using the keywords "Prevalence", "Hepatitis C", and "Prisoner" in the Iranian and international databases SID, MagIran, Iran Doc, Science Direct, Scopus, PubMed, and Web of Science (WoS) from January 1990 to September 2020. After transferring the articles to the information management software EndNote and eliminating duplicate studies, the remaining studies were reviewed based on inclusion and exclusion criteria, three stages of primary and secondary evaluation, and qualitative evaluation. Comprehensive meta-analysis software and Begg and Mazumdar and I² tests were used for data analysis and assessment of dissemination bias, and heterogeneity, respectively. Out of 93 studies (22 from Asia, 26 from Europe, seven from Africa, 29 from America, and nine from Australia) with a total sample size of 145,823 subjects, the prevalence of hepatitis C in prisoners worldwide was estimated to be 17.7% (95% confidence interval, 15-20.7%). The highest prevalence of hepatitis C on the continents included in this study was reported in prisoners incarcerated in Australia and Oceania, with 28.4% (95% CI: 21.6-36.4) in nine studies, and Europe, with 25.1% (95% CI: 19.4-31.8) in 26 studies. All studies used an ELISA test for the detection of HCV antibodies. The results showed a prevalence of HCV of 17.7% in prisoners worldwide, ranging between 10 and 30% over five continents (Asia, Europe, America, Africa, and Australia and Oceania). The highest prevalence was reported in Australia and Oceania (28.4%), indicating the need to pay more attention to this issue on the continent. It is necessary to reduce the incidence of the disease in prisons by appropriate policy-making and the development of accurate and practical programs, including the distribution of free syringes and examination, testing, and screening of prisoners.

New hepatitis C virus infection, re-infection and associated risk behaviour in male Irish prisoners: a cohort study, 2019

BACKGROUND

Prisoners are recognised as a high-risk population and prisons as high-risk locations for the transmission of hepatitis c virus (HCV) infection. Injecting drug use (IDU) is the main driver of HCV infection in prisoners and harm reduction services are often suboptimal in prison settings. HCV prevalence and incident data in prisoners is incomplete which impacts the public health opportunity that incarceration provides in identifying, treating and preventing HCV infection. The aim of this study is to identify new HCV infection and associated risk factors in an Irish male prison.

METHODS

We conducted a follow up (18-month) cohort study on prisoners who had previously tested negative, self-cleared or had been successfully treated for HCV infection. We conducted the study in a male medium security prison located in Dublin Ireland (Mountjoy Prison) using HCV serology, a review of medical records and a researcher-administered questionnaire.

RESULTS

99 prisoners with a mean age of 33.2 yrs. participated in the study and 82(82.8%) completed a research-administered questionnaire. Over half (51%) had a history of drug use from a young age (14.8 yrs.), 49.9% a history of heroin use and 39% a history of IDU. The prevalence of HIV and hepatitis B virus core antibody was 3% and HCV antibody was 22.2%. No new HCV infections were identified in those who had never been infected (n = 77), had self-cleared (n = 9) or achieved sustained virological response (n = 12). Small numbers of prisoners continued to engage in risk-behaviour including, IDU both in the prison (n = 2) and the community (n = 3), sharing syringes (n = 1) and drug taking paraphernalia (n = 6) and receiving non-sterile tattoos (n = 3).

CONCLUSION

Despite the high numbers of Irish prisoners with a history of IDU and HCV infection, new HCV infection is low or non-existent in this population. Small numbers of prisoners continue to engage in risk behaviour and larger studies are required to further understand HCV transmission in this cohort in an Irish and international context.

Hepatitis C elimination among people incarcerated in prisons: challenges and recommendations for action within a health systems framework

Hepatitis C virus (HCV) is a global public health problem in correctional settings. The International Network on Health and Hepatitis in Substance Users-Prisons Network is a special interest group committed to advancing scientific knowledge exchange and advocacy for HCV prevention and care in correctional settings. In this Review, we highlight seven priority areas and best practices for improving HCV care in correctional settings: changing political will, ensuring access to HCV diagnosis and testing, promoting optimal models of HCV care and treatment, improving surveillance and monitoring of the HCV care cascade, reducing stigma and tackling the social determinants of health inequalities, implementing HCV prevention and harm reduction programmes, and advancing prison-based research.

The Impact of Medications for Opioid Use Disorder on Hepatitis C Incidence Among Incarcerated Persons: A Systematic Review

Hepatitis C virus (HCV) is highly prevalent in the criminal justice system and in persons who inject drugs, particularly opioids. Data on the impact of medications for opioid use disorder (MOUD) are abundant for infectious and noninfectious outcomes but are limited for justice-involved settings. This systematic review and meta-analysis focuses on the impact of MOUD on HCV incidence for persons in prisons and jails. Six studies were included in the qualitative synthesis, of which four were included for meta-analysis. A varied MOUD effect on HCV incidence was observed in part due to wide variability in prison and jail risk environments.

Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach

Background and objective: Although the treatment of chronic hepatitis C (CHC) has significantly evolved with the introduction of direct-acting antivirals, the treatment uptake rates have been low especially among marginalized groups in the UK, such as people who inject drug (PWID) and men who have sex with men (MSM). Cutting health inequality is a major focus of healthcare agencies. This study aims to identify the optimal allocation of treatment budget for chronic hepatitis CHC among populations and treatments in the UK so that liver-related mortality in patients with CHC is minimized, given the constraint of treatment budget and equity issue. Methods: A constrained optimization modelling of resource allocation for the treatment of CHC was developed in Excel from the perspective of the UK National Health System over a lifetime horizon. The model was designated with the objective function of minimizing liver-related deaths by varying the decision variables, representing the number of patients receiving each treatment (elbasvir-grazoprevir, ombitasvir-paritaprevir-ritonavir-dasabuvir, sofosbuvir-ledipasvir, and pegylated interferon-ribavirin) in each population (the general population, PWID, and MSM). Two main constraints were formulated including treatment budget and the issue of equity. The model was populated with UK local data applying linear programming and underwent internal and external validation. Scenario analyses were performed to assess the robustness of model results. Results: Within the constraints of no additional funding over original spending in status quo and the consideration of the issue of equity among populations, the optimal allocation from the constrained optimization modelling (treating 13,122 PWID, 160 MSM, and 904 general patients with ombitasvir-paritaprevir-ritonavir-dasabuvir) was found to treat 2,430 more patients (relative change: 20.7%) and avert 78 liver-related deaths (relative change: 0.3%) compared with the current allocation. The number of patients receiving treatment increased 4,928 (relative change: 60.1%) among PWID and 42 (relative change: 35.8%) among MSM. Conclusion: The current allocation of treatment budget for CHC is not optimal in the UK. More patients would be treated, and more liver-related deaths would be avoided using a new allocation from a constrained optimization modelling without incurring additional spending and considering the issue of equity.

Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky

BACKGROUND

People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration.

METHODS

A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%.

RESULTS

Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration.

CONCLUSION

Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.

Fatal accident inquiries into 83 deaths in Scottish prison custody: 2010-2013

BACKGROUND

The only non-legal reference in Lord Cullen's Review of fatal accident inquiry (FAI) Legislation in Scotland (2009) was my audit of FAIs into 97 deaths in prison custody in Scotland, 1999-2003: recommending that waiting time from prisoner death to end of FAI should be less than 1 year for 90% of FAIs, and epidemiological rules for FAIs to have a written determination versus formal findings.

AIMS

Audit of FAIs into 83 deaths in Scottish prison custody in the period 2010-2013.

METHOD

Assessement of waiting times from prisoner death to end of FAI; dissemination of written determinations; self-inflicted death rate per 1000 prisoner-years; cause of natural deaths; and yellow card submissions. Detailed cross-checking was nec37essary between Scottish Prison Service and courts' websites and the Scottish Fatalities Investigation Unit.

RESULTS

Of 83 FAIs into deaths in Scottish prison custody, 2010-2013, 37 (45%) were long-awaited (ongoing >2 years after the prisoner's death); 16 (19%, 95% CI 11-28%) beyond 3 years. Of 37 long-awaited FAIs, 27 made written determinations but only 12 of these (44%) were published. Self-inflicted deaths numbered 36: 1.1 per 1000 prisoner-years (95% CI 0.75-1.48). Of 47 deaths from natural causes, cardiovascular disease accounted for 23 (49%, 95% CI 34-63%); liver disease was implicated in 10 of 47. To support pharmacovigilance, submissions were made to Medicines and Healthcare Regulatory Agency for eight deaths (10%, 95% CI 4-19%).

CONCLUSIONS

FAIs into prisoner deaths in Scotland are too long-awaited given that four (5%) identified precautions that could have prevented death.

Hepatitis C virus infection and its associated factors among prisoners in a Nigerian prison

Background

The prison population is considered at high risk of acquiring infectious diseases due to confined conditions, behavioral factors, injection drug use, unprotected sexual activity, non-professional tattooing and scarification, and needle sharing. Hepatitis C virus (HCV) is a blood borne pathogen mostly transmitted via percutaneous exposure that results in inflammation of the liver. It is one of the public health problem worldwide and is the principal cause of parenterally transmitted non-A, non-B hepatitis. The study was aimed at evaluating the prevalence of HCV among prison inmates in Calabar, Cross River State, Nigeria and the associated factors.

Methods

The study took a descriptive cross sectional approach using multi-stage sampling technique. One hundred and forty-two (142) prison inmates within the age range of 18–50 years and above were recruited for this study.

Result

Forty two (42); [29.6%] of the participating prison inmates were seropositive for HCV. Gender stratification showed that 31.0% of the males were seropositive for HCV while 15.4% of the females were seropositive for HCV. Fisher exact test showed that gender, age, marital status, occupation and level of education had no association in distribution of seroprevalence of HCV (p > 0.05) but the duration in prison was significantly associated with distribution of seropositivity of HCV in the studied population (p < 0.05). Bivariate logistic regression showed that tattoo/scarification, injection drug use, history of blood transfusion, sexual experience, shaving equipment sharing and multiple sexual partners were not risk factor for distribution of HCV prevalence in the studied population (p > 0.05). However, 23.5% who had tattoo/scarification, 29.6% who used injection drug, 33.3% who had history of blood transfusion, 29.8% who had sexual experience, 21.2% who shared shaving equipment, and 28.3% who had multiple sex partners were seropositive for HCV.

Conclusion

Approximately 29.6% prevalence of Hepatitis C virus infection observed among inmates studied is high and calls for concern. Attitude and behaviors by inmates such as tattooing/scarification, injection drugs use, sharing of shaving equipment, multiple sexual partners should be discouraged.

The seroprevalence of untreated chronic hepatitis C virus (HCV) infection and associated risk factors in male Irish prisoners: a cross-sectional study, 2017

IntroductionData on chronic hepatitis C (HCV) infection prevalence in European prisons are incomplete and impact the public health opportunity that incarceration provides.AimsWe aimed to estimate the seroprevalence of untreated chronic HCV infection and to identify associated risk factors in an Irish male prison.MethodsWe conducted a cross-sectional study involving a researcher-administered questionnaire, review of medical records and HCV serology.ResultsOf 422 prisoners (78.0% of the study population) who participated in the study, 298 (70.6%) completed the questionnaire and 403 (95.5%) were tested for HCV antibodies. Of those tested, 92 (22.8%) were HCV antibody-positive, and of those, 53 (57.6%) were HCV RNA-positive, 23 (25.0%) had spontaneous clearance, 16 (17.4%) had a sustained viral response, 10 (11.0%) were co-infected with HIV and six (6.0%) with HBV. The untreated chronic HCV seroprevalence estimate was 13.1% and the seroprevalence of HCV among prisoners with a history of injecting drug use (IDU) was 79.7%. Risk factors significantly associated with past HCV infection were IDU (p < 0.0001), having received a prison tattoo (p < 0.0001) or a non-sterile community tattoo (p < 0.0001), sharing needles and other drug-taking paraphernalia (p < 0.0001). Small numbers of prisoners had a history of sharing razors (n=10; 3.4%) and toothbrushes (n=3; 1.0%) while incarcerated. On multivariable analysis, history of receiving a non-sterile community tattoo was the only significant risk factor associated with HCV acquisition (after IDU was removed from the model) (p = 0.005, β = 0.468).ConclusionThe level of untreated chronic HCV infection in Irish prisons is high, with IDU the main associated risk.

Systematic Review and Meta-Analysis of Global Prevalence of HBsAg and HIV and HCV Antibodies among People Who Inject Drugs and Female Sex Workers

The main objective of this study was to evaluate the prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis C virus (HCV) and hepatitis B virus (HBV) and their co-infections among people who inject drugs (PWID) and female sex workers (FSWs). Data sources were searched from January 2008 to October 2018 in different databases. Data were analyzed in Stata 16 software using the Metaprop command. The results showed that the prevalence of HIV, HCV and HBV among PWID was 15%, 60% and 6%, respectively. The prevalence of HIV, HCV and HBV among FSWs was 5%, 1% and 3%, respectively. The prevalence of HIV/HCV, HIV/HBV, HCV/HBV and HIV/HCV/HBV co-infections among PWID was 13%, 2%, 3% and 2%, respectively. The prevalence of HIV/HCV and HIV/HBV co-infections among FSWs was 3% and 1%, respectively. The results show that the prevalence of HCV and HIV infections in PWID and the prevalence of HIV in FSWs is higher than their prevalence in the general population. Interventions for the prevention of HIV and HCV in PWID appear to be poor, and may not be sufficient to effectively prevent HIV and HCV transmission.

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

Time matters: Point of care screening and streamlined linkage to care dramatically improves hepatitis C treatment uptake in prisoners in England

BACKGROUND

In England, opt-out dry blood spot prison screening for HIV, hepatitis B and hepatitis C (HCV) has been introduced to scale-up access to care. Recent advances in point-of-care HCV diagnostics provide an opportunity to improve diagnosis and treatment uptake. We compared the retention along and time intervals between each aspect of the HCV care continuum for an alternative rapid point-of-care-testing and simplified treatment strategy with existing national opt-out HCV dry blood spot testing and treatment at a large remand prison in West London.

METHODS

Between September 2017 and December 2018 universal opt-out dry blood spot HCV testing, clinical assessment and treatment uptake were recorded at Her Majesty's Prison Wormwood Scrubs. Outcomes were compared to a point-of-care-based (salivary Oraquick® anti-HCV screening and Xpert® HCV fingerstick viral load) screening and streamlined treatment pathway offered to all new arrivals to the HMP Wormwood Scrubs substance misuse unit, which ran in parallel to dry blood spot testing between September and December 2018.

RESULTS

During the study period 2442 out of 5239 inmates (46.6%) underwent dry blood spot screening, resulting in 62 (2.6%) HCV RNA positive cases. Thirteen (21.3%) individuals commenced therapy and no viral relapse cases were observed to date. In comparison, 162 out of 181 (89.5%) inmates admitted to the substance misuse unit agreed to rapid point-of-care testing; 20 (12.3%) HCV RNA positive cases. Seventeen (85.0%) of eligible inmates commenced treatment. The median length of stay (90 vs 30 days), time to screening (6 vs 2 days), assessment (14 vs 3 days) and treatment (36 vs 1 day) were shorter for the rapid point-of-care screen-and-treat group.

CONCLUSION

Current scaling-up of prison dry blood spot HCV screening and treatment in England is sub-optimal. In our setting, the cascade of care is time and resource sensitive and is greatly improved by the introduction of a simplified screen-and-treat strategy.

Incidence, prevalence and risk factors for hepatitis C in Danish prisons

Hepatitis C virus (HCV) infection is prevalent among people in prison and prisons could therefore represent a unique opportunity to test risk groups for HCV. The aim of this sero-epidemiological study was to determine the incidence and prevalence of HCV infection and the corresponding risk factors in Danish prisons. Participants, recruited from eight Danish prisons, were tested for HCV using dried blood spots and filled out a questionaire with demographic data and risk factors for HCV infection. In total, 76.9% (801/1041) of all eligible prisoners consented to participate. The prevalence of HCV RNA positive prisoners was 4.2% (34/801) and the in-prison incidence rate was 0.7–1.0 per 100PY overall and 18-24/100PY among PWIDs. Infected prisoners were older than the overall population with a mean age of 42 years and only 17.6% (6/34) were younger than 35 years. The prevalence of PWID was 8.5% (68/801) and only 3% (2/68) of PWID were younger than 25 years. Among the PWID, 85.3% (58/68) had ever received opioid substitution therapy (OST) and 47.1% (32/68) were currently receiving OST. Risk factors associated with HCV infection were intravenous drug use, age ≥ 40 years, and being incarcerated ≥ 10 years. In conclusion, the prevalence of PWID in Danish prisons is low, possibly reflecting a decrease in injecting among the younger generation. This together with OST coverage could explain the low prevalence of HCV infection. However among PWIDs in prison the incidence remains high, suggesting a need for improved HCV prevention in prison.

Hepatitis B and C prevalence and incidence in key population groups with multiple risk factors in the EU/EEA: a systematic review

BackgroundPeople living with HIV (PLHIV) and people in prison are population groups with a potentially high risk and/or prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection.AimWe conducted a systematic review in order to find prevalence and incidence estimates in these populations in the European Union/European Economic Area (EU/EEA).MethodsOriginal research articles published between January 2005 and February 2017 were retrieved from PubMed and Embase in February 2017.ResultsFifty-two articles were included, providing 97 estimates of HBV/HCV infection prevalence or incidence. Estimates of HBV infection prevalence ranged between 2.9% and43.4% in PLHIV and 0.0% and 25.2% in people in prison. Estimates of HCV infection prevalence ranged from 2.9% to 43.4% in PLHIV and 0.0% to 25.2% in people in prison. Incidence estimates ranged between 0.0 and 2.5 cases per 100 person-years for HBV infection in PLHIV. No such data was available for people in prison. HCV infection incidence ranged between 0.3 and 0.9 cases per 100 person-years in PLHIV and between 1 and 1.2 cases per 100 person-years in people in prison. Prevalence estimates were generally higher than in the general population, especially for HCV infection and among groups with multiple risk factors.ConclusionsPLHIV, people in prison and groups with multiple risk factors, have a high prevalence of HBV and HCV and may be at ongoing risk of infection. These groups should be among the populations prioritised and targeted for active case finding and prevention programmes in the EU/EEA.

Testing for hepatitis C virus infection in UK prisons: What actually happens?

Prisons are a key demographic in the drive to eradicate hepatitis C virus (HCV) as a major public health threat. We have assessed the impact of the recently introduced national opt-out policy on the current status of HCV testing in 14 prisons in the East Midlands (UK). We analysed testing rates pre- and post-introduction of opt-out testing, together with face-to-face interviews with prison healthcare and management staff in each prison. In the year pre-opt-out, 1972 people in prison (PIP) were tested, compared to 3440 in the year following opt-out. From July 2016 to June 2017, 2706 people were tested, representing 13.5% of all prison entrants (median 16.6%, range 7.6%-40.7%). Factors correlating with testing rates were as follows: pre-admission location of the PIP (another prison or the community, OR 2.2, 95% CI 1.9-2.3, P < 0.001); whether the PIP could access health care independently of prison officers (OR 1.7, 95% CI 1.5-1.8, P < 0.001); the absence of out-reach services for HCV treatment (OR 1.3, 95% CI 1.2-1.5, P < 0.001), whether >50% of PIP reported ease of access to a nurse (OR 2.0, 95% CI 1.8-2.2, P < 0.001), and whether prison health care was supplied by private or NHS providers (OR 1.3, 95% CI 1.2-1.5, P < 0.001). Testing rates remained far below the minimum national opt-out target of 50%. Inadequacy of healthcare facilities and constraints imposed by adherence to prison regimens were cited by healthcare and management staff at all prisons. Without radical change, the prison estate may be intrinsically incapable of supporting NHSE to deliver the HCV elimination strategy.

Non drug-related and opioid-specific causes of 3262 deaths in Scotland's methadone-prescription clients, 2009-2015

BACKGROUND

Opioid drug use is a major cause of premature mortality, with opioid substitution therapy the leading intervention. As methadone-clients age, non-drug-related deaths (non-DRDs) predominate and DRD-risks increase differentially, quadrupling at 45+ years for methadone-specific DRDs.

METHODS

36,606 methadone-prescription-clients in Scotland during 2009-2015 were linked to mortality records to end-2015 by their Community Health Index (CHI). Cohort-entry, also baseline quantity of prescribed methadone, were defined by clients' first CHI-identified methadone-prescription during 2009-2015. National Records of Scotland identified non-DRDs from DRDs; and provided ICD10 codes for underlying and co-present causes of death. Methadone-specific DRD means methadone was implicated in DRD but neither heroin nor buprenorphine.

RESULTS

During 193,800 person-years of follow-up, 1939 non-DRDs (59%) and 1323 DRDs occurred, of which 546 were methadone-specific. Predominant underlying ICD10 chapters for non-DRDs were: neoplasm (377); external causes (341); diseases of digestive (303), circulatory (286) or respiratory (212) system. As methadone-clients aged, the non-DRD proportion of their deaths increased from 54% (717/1318) at 35-44 years to 89% (372/417) at 55+ years. After allowing for DRDs' opioid-specificity, age-group and quintile for last-prescribed methadone, there was a significant, positive interaction for co-present circulatory disease between top-quintile for prescribed methadone and 45+ years at death (p = 0.033 after Bonferroni); not for digestive or respiratory co-presence.

CONCLUSIONS

Circulatory disease is the co-morbidity most likely implicated in the quadrupling of methadone-specific DRD-risk at 45+ years; followed by digestive disease. Cultural shift is needed in treatment-services because degenerative non-DRDs predominate as methadone-clients age. Future linkage-studies should access hospitalizations and methadone-daily-dose.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

HIV and Viral Hepatitis Among Imprisoned Key Populations

Prisons and other closed facilities create opportunities for transmission of human immunodeficiency virus (HIV) and viral hepatitis during detention and after release. We conducted a systematic review and meta-analysis of peer-reviewed publications (2005-2015) to describe the prevalence of HIV, hepatitis C virus, and hepatitis B virus among key populations in prisons worldwide and to compare estimates of infection with those of other prison populations. Most data were reported for people who inject drugs (PWID; n = 72) and for men who have sex with men (MSM; n = 21); few data were reported on sex workers (SW; n = 6), or transgender women (n = 2). Publications were identified from 29 countries, predominantly middle- and high-income countries. Globally, PWID had 6 times the prevalence of HIV (pooled prevalence ratio (PPR) = 6.0, 95% CI: 3.8, 9.4), 8 times the prevalence of hepatitis C virus (PPR = 8.1, 95% CI: 6.4, 10.4), and 2 times the prevalence of hepatitis B virus (PPR = 2.0, 95% CI: 1.5, 2.7) compared with noninjecting prisoner populations. Among these articles, only those from Iran, Scotland, Spain, and Italy included the availability of methadone therapy; 2 articles included information on access to needle exchange programs by PWID detainees. HIV prevalence was more than 2 times higher among SW (PPR = 2.6, 95% CI: 2.2, 3.1) and 5 times higher among MSM (PPR = 5.3, 95% CI: 3.5, 7.9) compared with other prisoners. None of these articles reported HIV prevention coverage among SW or transgender women; 1 described HIV and sexually transmitted infection screening for MSM in prison. Prevention programs specific to key populations are important, particularly for populations that are criminalized and/or may cycle in and out of prison.

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity.

FINDINGS

We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

INTERPRETATION

Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

FUNDING

Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

Hepatitis C among vulnerable populations: A seroprevalence study of homeless, people who inject drugs and prisoners in London

Injecting drugs substantially increases the risk of hepatitis C virus (HCV) infection and is common in the homeless and prisoners. Capturing accurate data on disease prevalence within these groups is challenging but is essential to inform strategies to reduce HCV transmission. The aim of this study was to estimate the prevalence of HCV in these populations. We conducted a cross-sectional study between May 2011 and June 2013 in London and, using convenience sampling, recruited participants from hostels for the homeless, drug treatment services and a prison. A questionnaire was administered and blood samples were tested for hepatitis C. We recruited 491 individuals who were homeless (40.7%), 205 drug users (17%) and 511 prisoners (42.3%). Eight per cent of patients (98/1207, 95% CI: 6.7%-9.8%) had active HCV infection and 3% (38/1207, 95% CI: 2.3%-4.3%) past HCV infection. Overall, one quarter (51/205) of people recruited in drug treatment services, 13% (65/491) of people from homeless residential sites and 4% (20/511) prisoners in this study were anti-HCV positive. Seventy-seven of the 136 (56.6%, 95% CI: 47.9%-65%) of HCV infected participants identified had a history of all three risk factors (homelessness, imprisonment and drug use), 27.3% (95% CI: 20.1%-35.6%) had 2 overlapping risk factors, and 15.4% (95% CI: 10.6%-23.7%) one risk factor. Drug treatment services, prisons and homelessness services provide good opportunities for identifying hepatitis C-infected individuals. Effective models need to be developed to ensure case identification in these settings that can lead to an effective treatment and an efficient HCV prevention.

Hepatitis C seropositivity among newly incarcerated prisoners in Estonia: data analysis of electronic health records from 2014 to 2015

Background

Hepatitis C virus (HCV) infection is a widespread problem in prisons. The present study aimed to assess the prevalence of HCV seropositivity, HCV genotypes, factors associated with HCV seropositivity in newly incarcerated prisoners and to report experiences of treatment with pegylated interferon/ribavirin for HCV-positive inmates.

Methods

Patient data were extracted from the Estonian prison medical information system (Vanglate meditsiiniline infosüsteem) databases.

Results

Among 1845 prisoners newly incarcerated from January 2014 to January 2015, the overall prevalence of HCV was 56.3% (95% CI: 54 to 59), and 25.5% (95% CI: 23.5 to 27.6%) had HIV (39.0% had neither). The all-inclusive HCV testing strategy identified 37.7% more HCV infected prisoners than the risk-based (drug use history, HIV status) case finding. Factors associated with HCV seropositivity included history of drug use (aOR 6.51 95%CI 5.12–8.28), HIV co-infection (aOR 2.56 95%CI 1.92–3.43), previous incarceration (aOR 3.61 95%CI 2.48–4.04), and increasing age. The main HCV genotypes were 3a (n = 172, 44.4%) and 1b (n = 135, 35.2%). Twenty-five prisoners received HCV treatment: 60% (n = 15) were cured, 16% (n = 4) relapsed (3 with genotype 3a, one with 1b), and 12% (n = 3) were unresponsive (all with genotype 3a).

Conclusions

HCV seropositivity rate is high and HCV tretment rate is very low in Estonian prisons. Optimizing case finding and scaling up treatment is critical to addressing the health needs of prisoners and meeting public health goals.

Tattooing in prison: a risk factor for HCV infection among inmates in the Quebec's provincial correctional system

PURPOSE

To determine the prevalence of hepatitis C virus (HCV) and identify related risk factors among inmates in Quebec provincial prisons.

METHODS

Anonymous cross-sectional data were collected between May 2014 and March 2015 for 1315 men and 250 women who completed a questionnaire and provided oral fluid samples.

RESULTS

The global prevalence of HCV infection was 11.9% in male participants and 19.2% in female participants (P = .003). Among people who inject drugs (PWID), the prevalence was much higher compared to that in persons who does not: 51.0% versus 2.4% in men (P < .001) and 61.4% versus 2.8% in women (P < .001). In the multivariable analysis, lifetime history of injection drug use was the most important risk factor for HCV infection (adjusted odds ratio [AOR]: 14.2; 95% confidence interval [95% CI]: 9.5-21.4), with needle sharing significantly associated with HCV among PWID (AOR: 1.4; 95% CI: 1.1-1.7). Tattooing in prison was frequent, especially among men (37.2%), and independently associated with HCV infection among non-PWID (AOR: 2.8; 95% CI: 1.4-5.6).

CONCLUSION

Inmates are at high risk for HCV infection especially because of a high proportion of active or past PWID among them. In addition, tattooing while in prison seems to contribute to HCV infection among non-PWID.

Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England

BACKGROUND AND AIMS

People with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk.

DESIGN

Prospective observational cohort study using prison health care, national community drug misuse treatment and deaths registers.

SETTING

Recruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning.

PARTICIPANTS

Adult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n = 15 141 in the risk set).

INTERVENTION AND COMPARATOR

At release, participants were classified as OST exposed (n = 8645) or OST unexposed (n = 6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose.

MEASUREMENTS

Primary outcome: all-cause mortality (ACM) in the first 4 weeks.

SECONDARY OUTCOMES

drug-related poisoning (DRP) deaths in the first 4 weeks; ACM and DRP mortality after 4 weeks to 1 year; admission to community drug misuse treatment in the first 4 weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake.

FINDINGS

During the first 4 weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR) = 0.25; 95% confidence interval (CI) = 0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR = 0.15; 95% CI = 0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI = 2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR = 0.25; 95% CI = 0.09-0.64 and HR = 0.15; 95% CI = 0.04-0.52, respectively).

CONCLUSIONS

In an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.

Modelling the impact of incarceration and prison-based hepatitis C virus (HCV) treatment on HCV transmission among people who inject drugs in Scotland

BACKGROUND AND AIMS

People who inject drugs (PWID) experience high incarceration rates, and previous incarceration is associated with elevated hepatitis C virus (HCV) transmission risk. In Scotland, national survey data indicate lower HCV incidence in prison than the community (4.3 versus 7.3 per 100 person-years), but a 2.3-fold elevated transmission risk among recently released (< 6 months) PWID. We evaluated the contribution of incarceration to HCV transmission among PWID and the impact of prison-related prevention interventions, including scaling-up direct-acting antivirals (DAAs) in prison.

DESIGN

Dynamic mathematical modelling of incarceration and HCV transmission, using approximate Bayesian computation for model calibration.

SETTING

Scotland, UK.

PARTICIPANTS

A simulated population of PWID.

MEASUREMENTS

Population-attributable fraction (PAF) of incarceration to HCV transmission among PWID. Decrease in HCV incidence and chronic prevalence due to current levels of prison opiate substitution therapy (OST; 57% coverage) and HCV treatment, as well as scaling-up DAAs in prison and/or preventing the elevated risk associated with prison release.

FINDINGS

Incarceration contributes 27.7% [PAF; 95% credible interval (CrI) -3.1 to 51.1%] of HCV transmission among PWID in Scotland. During the next 15 years, current HCV treatment rates (10.4/6.8 per 1000 incarcerated/community PWID annually), with existing prison OST, could reduce incidence and chronic prevalence among all PWID by a relative 10.7% (95% CrI = 8.4-13.3%) and 9.7% (95% CrI = 7.7-12.1%), respectively. Conversely, without prison OST, HCV incidence and chronic prevalence would decrease by 3.1% (95% CrI = -28.5 to 18.0%) and 4.7% (95% CrI = -11.3 to 14.5%). Additionally, preventing the heightened risk among recently released PWID could reduce incidence and chronic prevalence by 45.0% (95% CrI = 19.7-57.5%) and 33.3% (95% CrI = 15.6-43.6%) or scaling-up prison HCV treatments to 80% of chronic PWID prison entrants with sufficient sentences (>16 weeks) could reduce incidence and prevalence by 45.6% (95% CrI = 38.0-51.3%) and 45.5% (95% CrI = 39.3-51.0%), respectively.

CONCLUSIONS

Incarceration and the elevated transmission risk following prison release can contribute significantly to hepatitis C virus transmission among people who inject drugs. Scaling-up hepatitis C virus treatment in prison can provide important prevention benefits.

Association between harm reduction intervention uptake and skin and soft tissue infections among people who inject drugs

BACKGROUND

Bacterial skin and soft tissue infections (SSTIs) are a health issue for people who inject drugs (PWID). There is a lack of evidence on the associations between harm reduction (HR) uptake and SSTIs. This paper examines the associations between the uptake of injecting equipment (IE) and opiate substitution treatment (OST) on SSTIs among PWID, and the injecting behaviours associated with having had an SSTI. This is the first large-scale, national study to examine the association between IE uptake and SSTIs.

METHODS

A cross-sectional, voluntary and anonymous survey was undertaken with PWID recruited from pharmacies/agencies providing IE across mainland Scotland during 2013-2014. Participants were asked: if they had an SSTI within the past year; about their uptake of HR within the past 6 months (including needle/syringes (N/S), paraphernalia and OST); and about their frequency of injecting, sharing of IE and re-use of own N/S. Data from 1876 PWID who had reported injecting within the past 6 months were analysed.

FINDINGS

In multivariate logistic regression, those with high combined IE-OST uptake (adjusted odds ratio [AOR] 0.614, 95% CI 0.458-0.823, p=0.001) and medium combined IE-OST uptake (AOR 0.725, 95% CI 0.546-0.962, p=0.026) had lower odds of having had an SSTI compared to those with low combined IE-OST uptake.

CONCLUSIONS

IE and OST uptake may reduce the level of SSTIs among PWID, suggesting increasing combined uptake may be beneficial. Nevertheless, a sizeable proportion of PWID with high HR uptake experienced SSTIs, suggesting the importance of other interventions.

Prison officers' views about hepatitis C testing and treatment: a qualitative enquiry

AIMS AND OBJECTIVES

To explore the views of prison officers in an English category B male prison about people in prison being tested and treated for hepatitis C.

BACKGROUND

Hepatitis C testing and treatment in English prisons remain low with the reasons being poorly understood. Prison officers are in continuous contact with prisoners so might observe factors that may influence people in prisons' choice in whether to accept hepatitis C testing and treatment.

DESIGN

A qualitative design within an interpretative framework was employed.

METHODS

Semistructured interviews were conducted with 10 prison officers at an English male category B prison. The interviews were audiorecorded and transcribed at the prison.

RESULTS

Four themes emerged Safeguarding, Stigma, Confidentiality and Education. Hepatitis C testing and treatment were supported in principle but if a person in prison poses a threat to the overall security of a prison, any health issues that are not immediately life threatening will be overridden, irrespective of the financial or health consequences. The prison officers respected people in prisons' confidentiality regarding health matters, but this could be compromised during violent incidents. All of the prison officers displayed limited knowledge about hepatitis C.

CONCLUSIONS

This qualitative enquiry illustrates that prison security transcends health. This suggests that health providers may need to offer greater flexibility and collaboration across the network of National Health Service hospitals to maintain continuity in treatment if a prisoner is moved to a different establishment or liberated.

RELEVANCE TO CLINICAL PRACTICE

This study introduces the notion that prison security staff may have a potential role in promoting or discouraging hepatitis C testing and treatment by the ways in which their knowledge impacts on their interactions with people in prison. Engaging this staff group in educational opportunities should be a component of commissioned hepatitis service delivery in prisons.

Injecting drug use, sexual risk, HIV knowledge and harm reduction uptake in a large prison in Bali, Indonesia

PURPOSE

The purpose of this paper is to describe HIV-related risk behavior and knowledge of HIV among inmates of Kerobokan prison Bali, Indonesia.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional survey of inmates of using a structured questionnaire and sample framework to reflect narcotic use among inmates and the prison gender mix.

FINDINGS

Among 230 inmates recruited to the study self-reported prevalence of injecting drug use was 7.4 percent (95 percent CI 4.0-10.8 percent). Respondents who participated in a prison based methadone treatment program were all still injecting drugs, these made up 13/17 of the IDU. In total, 47 percent (95 percent CIs 45-55 percent) of respondents who reported injecting also reported sharing needles within the last week. Sexual intercourse while in prison was reported by 3.0 percent (95 percent CI 0.82-5.26 percent) of study respondents. One-third of non-injectors were unaware of the preventative role of condom use. This study suggests that despite harm reduction initiatives within Kerobokan prison HIV risk behavior continues and there is a considerable lack of awareness of the importance of condom use in preventing HIV.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors relied on self-reported risk behavior that may be subject to reporting bias. The sampling strategy may not reflect the true ratio inmates using or not using narcotics.

PRACTICAL IMPLICATIONS

The current harm reduction approach, including methadone substitution treatment should be optimized within the Indonesian prison setting.

ORIGINALITY/VALUE

This is the first study reporting HIV-related risk behavior from an Indonesian prison with an established methadone substitution program.

A matched comparison study of hepatitis C treatment outcomes in the prison and community setting, and an analysis of the impact of prison release or transfer during therapy

Prisoners are a priority group for hepatitis C (HCV) treatment. Although treatment durations will become shorter using directly acting antivirals (DAAs), nearly half of prison sentences in Scotland are too short to allow completion of DAA therapy prior to release. The purpose of this study was to compare treatment outcomes between prison- and community-based patients and to examine the impact of prison release or transfer during therapy. A national database was used to compare treatment outcomes between prison treatment initiates and a matched community sample. Additional data were collected to investigate the impact of release or transfer on treatment outcomes. Treatment-naïve patients infected with genotype 1/2/3/4 and treated between 2009 and 2012 were eligible for inclusion. 291 prison initiates were matched with 1137 community initiates: SVRs were 61% (95% CI 55%-66%) and 63% (95% CI 60%-66%), respectively. Odds of achieving a SVR were not significantly associated with prisoner status (P=.33). SVRs were 74% (95% CI 65%-81%), 59% (95% CI 42%-75%) and 45% (95% CI 29%-62%) among those not released or transferred, transferred during treatment, or released during treatment, respectively. Odds of achieving a SVR were significantly associated with release (P<.01), but not transfer (P=.18). Prison-based HCV treatment achieves similar outcomes to community-based treatment, with those not released or transferred during treatment doing particularly well. Transfer or release during therapy should be avoided whenever possible, using anticipatory planning and medical holds where appropriate.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Review article: treatment as prevention - targeting people who inject drugs as a pathway towards hepatitis C eradication

BACKGROUND

Hepatitis C virus (HCV) is a leading cause of chronic liver disease worldwide. HCV predominates in people who inject drugs; a group in whom anti-viral therapy has previously been withheld on the basis of chaotic lifestyles and associated risks of reinfection. New research has emerged which suggests that by specifically targeting HCV-infected people who inject drugs for treatment, the pool of HCV would deplete, thus reducing overall transmission and eventually leading to HCV eradication.

AIM

To outline the requirements for HCV eradication and review the evidence that this is achievable.

METHODS

Expert review of the literature.

RESULTS

The achievement of HCV eradication using 'treatment as prevention' is supported by numerous epidemiological modelling studies employing a variety of models in several contexts including people who inject drugs, men who have sex with men and prisoners. More recent studies also incorporate the newer, more efficacious direct-acting anti-viral drugs. These drugs have been shown to be safe and effective in people who inject drugs in clinical trials. There is no empirical evidence of the impact of treatment as prevention strategies on population prevalence.

CONCLUSIONS

This review highlights the efforts to control HCV and evaluates the possibilities of achieving eradication of HCV. Currently, the technologies required to achieve HCV eradication exist, but the infrastructure to deliver them is not generally available or of insufficient scale outside of specific areas. Such areas are yet to demonstrate that elimination is possible, but results of studies in these areas are awaited. Such a demonstration would be proof of principle for eradication. Although we are aspiring towards HCV eradication, elimination is the more realistic prospect.

Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison

AIMS

To assess the effectiveness for Scotland's National Naloxone Programme (NNP) by comparison between 2006-10 (before) and 2011-13 (after NNP started in January 2011) and to assess cost-effectiveness.

DESIGN

This was a pre-post evaluation of a national policy. Cost-effectiveness was assessed by prescription costs against life-years gained per opioid-related death (ORD) averted.

SETTING

Scotland, in community settings and all prisons.

INTERVENTION

Brief training and standardized naloxone supply became available to individuals at risk of opioid overdose.

MEASUREMENTS

ORDs as identified by National Records of Scotland. Look-back determined the proportion of ORDs who, in the 4 weeks before ORD, had been (i) released from prison (primary outcome) and (ii) released from prison or discharged from hospital (secondary). We report 95% confidence intervals for effectiveness in reducing the primary (and secondary) outcome in 2011-13 versus 2006-10. Prescription costs were assessed against 1 or 10 life-years gained per averted ORD.

FINDINGS

In 2006-10, 9.8% of ORDs (193 of 1970) were in people released from prison within 4 weeks of death, whereas only 6.3% of ORDs in 2011-13 followed prison release (76 of 1212, P < 0.001; this represented a difference of 3.5% [95% confidence interval (CI) = 1.6-5.4%)]. This reduction in the proportion of prison release ORDs translates into 42 fewer prison release ORDs (95% CI = 19-65) during 2011-13, when 12,000 naloxone kits were issued at current prescription cost of £225,000. Scotland's secondary outcome reduced from 19.0 to 14.9%, a difference of 4.1% (95% CI = 1.4-6.7%).

CONCLUSIONS

Scotland's National Naloxone Programme, which started in 2011, was associated with a 36% reduction in the proportion of opioid-related deaths that occurred in the 4 weeks following release from prison.

Public health and international drug policy

In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role.

The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact.

The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs.

The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.

Impact of opioid substitution therapy for Scotland's prisoners on drug-related deaths soon after prisoner release

AIM

To assess whether the introduction of a prison-based opioid substitution therapy (OST) policy was associated with a reduction in drug-related deaths (DRD) within 14 days after prison release.

DESIGN

Linkage of Scotland's prisoner database with death registrations to compare periods before (1996-2002) and after (2003-07) prison-based OST was introduced.

SETTING

All Scottish prisons.

PARTICIPANTS

People released from prison between 1 January 1996 and 8 October 2007 following an imprisonment of at least 14 days and at least 14 weeks after the preceding qualifying release.

MEASUREMENTS

Risk of DRD in the 12 weeks following release; percentage of these DRDs which occurred during the first 14 days.

FINDINGS

Before prison-based OST (1996-2002), 305 DRDs occurred in the 12 weeks after 80 200 qualifying releases, 3.8 per 1000 releases [95% confidence interval (CI) = 3.4-4.2]; of these, 175 (57%) occurred in the first 14 days. After the introduction of prison-based OST (2003-07), 154 DRDs occurred in the 12 weeks after 70 317 qualifying releases, a significantly reduced rate of 2.2 per 1000 releases (95% CI = 1.8-2.5). However, there was no change in the proportion which occurred in the first 14 days, either for all DRDs (87: 56%) or for opioid-related DRDs.

CONCLUSIONS

Following the introduction of a prison-based opioid substitution therapy (OST) policy in Scotland, the rate of drug-related deaths in the 12 weeks following release fell by two-fifths. However, the proportion of deaths that occurred in the first 14 days did not change appreciably, suggesting that in-prison OST does not reduce early deaths after release.

Hepatitis C virus infection and prisoners: Epidemiology, outcome and treatment

The studies on hepatitis C virus (HCV) infection in prison populations are few and mostly cross-sectional. We analyzed prevalently the articles appearing on PubMed in the last ten years. HCV infection is frequent in prisoners, prevalences ranging from 3.1% to 38% according to the HCV endemicity in the geographical location of the prison and in the countries of origin of the foreign prisoners and to the prevalence of intravenous drug use, which is the most important risk factor for HCV infection, followed by an older age of prisoners and previous prison terms. HCV replication in anti-HCV-positive cases varies from 45% to 90% in different studies, and the most common HCV genotypes are generally 1 and 3. The response to antiviral treatment is similar in prisoners to that of the general population. Unfortunately, treatment is administered less frequently to prisoners because of the difficulties in management and follow-up. The new directly acting antivirals offer a good therapy option for inmates because of their good efficacy, short duration of treatment and low incidence of side effects. The efforts of the prison authorities and medical staff should be focused on reducing the spread of HCV infection in prisons by extending the possibility of follow-up and treatment to more prisoners with chronic hepatitis C.

The hepatitis C virus epidemics in key populations (including people who inject drugs, prisoners and MSM): the use of direct-acting antivirals as treatment for prevention

PURPOSE OF REVIEW

The burden of hepatitis C virus (HCV) is high among people who inject drugs (PWID) and prisoners, and increasing among HIV-infected MSM, who are key populations for HCV transmission in high-income countries and may also play a role in many in low- and middle-income countries. There is an increasing interest in the use of HCV antiviral treatment for prevention in these populations.

RECENT FINDINGS

Numerous theoretical modelling studies have explored the potential impact of HCV treatment for prevention among PWID in a range of global settings, generally finding that modest and achievable levels of HCV treatment, especially with interferon-free direct-acting antiviral therapy (IFN-free DAAs), could substantially reduce HCV chronic prevalence among PWID within the next 10-20 years. In addition, modelling studies have shown HCV testing and treatment in prison (including prevention benefits) could be cost-effective if continuity of care is ensured, or HCV treatments are shortened with DAAs. Modelling work among HIV-infected MSM has shown that further HCV treatment scale-up is likely required despite high treatment rates in this population. However, no empirical studies have explored whether HCV treatment can reduce HCV prevalence and prevent onwards transmission among those at risk of transmission.

SUMMARY

HCV treatment for key populations such as PWID, prisoners and MSM could become an important HCV prevention intervention, especially in the IFN-free DAA era. However, there is an urgent need to test these hypotheses through empirical studies.

Epidemiology of hepatitis C in Croatia in the European context

We analyzed prevalence, risk factors and hepatitis C virus (HCV) genotype distribution in different population groups in Croatia in the context of HCV epidemiology in Europe, with the aim to gather all existing information on HCV infection in Croatia which will be used to advise upon preventive measures. It is estimated that 35000-45000 of the Croatian population is chronically infected with HCV. Like in other European countries, there have been changes in the HCV epidemiology in Croatia over the past few decades. In some risk groups (polytransfused and hemodialysis patients), a significant decrease in the HCV prevalence was observed after the introduction of routine HCV screening of blood/blood products in 1992. Injecting drug users (IDUs) still represent a group with the highest risk for HCV infection with prevalence ranging from 29% to 65%. Compared to the prevalence in the Croatian general population (0.9%), higher prevalence rates were found in prison populations (8.3%-44%), human immunodeficiency virus-infected patients (15%), persons with high-risk sexual behavior (4.6%) and alcohol abusers (2.4%). Low/very low prevalence was reported in children and adolescents (0.3%) as well as in blood donors (0%-0.009%). In addition, distribution of HCV genotypes has changed due to different routes of transmission. In the general population, genotypes 1 and 3 are most widely distributed (60.4%-79.8% and 12.9%-47.9%, respectively). The similar genotype distribution is found in groups with high-risk sexual behavior. Genotype 3 is predominant in Croatian IDUs (60.5%-83.9%) while in the prison population genotypes 3 and 1 are equally distributed (52.4% and 47.6%). Data on HCV prevalence and risk factors for transmission are useful for implementation of preventive measures and HCV screening.

Prevalence of hepatitis C virus in Brazil's inmate population: a systematic review

OBJECTIVE

To estimate the prevalence of hepatitis C virus infection in Brazil’s inmate population.

METHODS

Systematic review on hepatitis C virus infection in the inmate population. Brazilian studies published from January 1, 1989 to February 20, 2014 were evaluated. The methodological quality of the studies was assessed using a scale of 0 to 8 points.

RESULTS

Eleven eligible studies were analyzed and provided data on hepatitis C virus infection among 4,375 inmates from seven states of Brazil, with a mean quality classification of 7.4. The overall hepatitis C virus prevalence among Brazilian inmates was 13.6% (ranging from 1.0% to 41.0%, depending on the study). The chances of inmates being seropositive for hepatitis C virus in the states of Minas Gerais (MG), Sergipe (SE), Mato Grosso do Sul (MS), Rio Grande do Sul (RS), Goiás (GO) and Espirito Santo (ES) were 84.0% (95%CI 0.06;0.45), 92.0% (95%CI 0.04;0.13), 88.0% (95%CI 0.09;0.18), 74.0% (95%CI 0.16;0.42), 84.0% (95%CI 0.08;0.31) and 89.0% (95%CI 0.01;0.05) respectively, lower than that observed in the Sao Paulo state (seroprevalence of 29.3%). The four studies conducted in the city of Sao Paulo revealed a lower prevalence in more recent studies compared to older ones.

CONCLUSIONS

The highest prevalence of hepatitis C virus infection in Brazil’s inmate population was found in Sao Paulo, which may reflect the urban diversity of the country. Despite Brazilian studies having good methodological quality to evaluate the prevalence of the hepatitis C virus, they are scarce and lack data on risk factors associated with this infection, which could support decisions on prevention and implementation of public health policies for Brazilian prisons.

Modeling the initiation of others into injection drug use, using data from 2,500 injectors surveyed in Scotland during 2008-2009

The prevalence of injection drug use has been of especial interest for assessment of the impact of blood-borne viruses. However, the incidence of injection drug use has been underresearched. Our 2-fold aim in this study was to estimate 1) how many other persons, per annum, an injection drug user (IDU) has the equivalent of full responsibility (EFR) for initiating into injection drug use and 2) the consequences for IDUs' replacement rate. EFR initiation rates are strongly associated with incarceration history, so that our analysis of IDUs' replacement rate must incorporate when, in their injecting career, IDUs were first incarcerated. To do so, we have first to estimate piecewise constant incarceration rates in conjunction with EFR initiation rates, which are then combined with rates of cessation from injecting to model IDUs' replacement rate over their injecting career, analogous to the reproduction number of an epidemic model. We apply our approach to Scotland's IDUs, using over 2,500 anonymous injector participants who were interviewed in Scotland's Needle Exchange Surveillance Initiative during 2008–2009. Our approach was made possible by the inclusion of key questions about initiations. Finally, we extend our model to include an immediate quit rate, as a reasoned compensation for higher-than-expected replacement rates, and we estimate how high initiates' quit rate should be for IDUs' replacement rate to be 1.

Take-home naloxone to prevent fatalities from opiate-overdose: Protocol for Scotland's public health policy evaluation, and a new measure to assess impact

Aims: Scotland was the first country to adopt take-home naloxone (THN) as a funded public health policy. We summarise the background and rigorous set-up for before/after monitoring to assess the impact on high-risk opiate-fatalities. Methods: Evidence-synthesis of prospectively monitored small-scale THN schemes led to a performance indicator for distribution of THN-kits relative to opiate-related deaths. Next, we explain the primary outcome and statistical power for Scotland's before/after monitoring. Results: Fatality-rate at opiate overdoses witnessed by THN-trainees was 6% (9/153, 95% CI: 2-11%). National THN-schemes should aim to issue 20 times as many THN-kits as there are opiate-related deaths per annum; and at least nine times as many. Primary outcome for evaluating Scotland's THN policy is reduction in the percentage of all opiate-related deaths with prison-release as a 4-week antecedent. Scotland's baseline period is 2006-10, giving a denominator of 1970 opiate-related deaths. A priori plausible effectiveness was 20-30% reduction, relative to baseline, in the proportion of opiate-related deaths that had prison-release as a 4-week antecedent. A secondary outcome was also defined. Conclusion: If Scotland's THN evaluation shifts the policy ground seismically, our new performance measure may prove useful on how many THN-kits nations should provide annually.

A prospective study of hepatitis C incidence in Australian prisoners

AIMS

To document the relationships between injecting drug use, imprisonment and hepatitis C virus (HCV) infection.

DESIGN

Prospective cohort study.

SETTING

Multiple prisons in New South Wales, Australia.

PARTICIPANTS

HCV seronegative prisoners with a life-time history of injecting drug use (IDU) were enrolled and followed prospectively (n = 210) by interview and HCV antibody and RNA testing 6-12-monthly for up to 4 years when in prison.

MEASUREMENTS

HCV incidence was calculated using the person-years method. Cox regression was used to identify predictors of incident infection using time-dependent covariates.

RESULTS

Almost half the cohort reported IDU during follow-up (103 subjects; 49.1%) and 65 (31%) also reported sharing of the injecting apparatus. There were 38 HCV incident cases in 269.94 person-years (py) of follow-up with an estimated incidence of 14.08 per 100 py [confidence interval (CI) = 9.96-19.32]. Incident infection was associated independently with Indigenous background, injecting daily or more and injecting heroin. Three subjects were RNA-positive and antibody-negative at the incident time-point, indicating early infection, which provided a second incidence estimate of 9.4%. Analysis of continuously incarcerated subjects (n = 114) followed over 126.73 py, identified 13 new HCV infections (10.26 per 100 py, CI = 5.46-17.54), one of which was an early infection case. Bleach-cleansing of injecting equipment and opioid substitution treatment were not associated with a significant reduction in incidence.

CONCLUSIONS

In New South Wales, Australia, imprisonment is associated with high rates of hepatitis C virus transmission. More effective harm reduction interventions are needed to control HCV in prison settings.

Incidence and correlates of hepatitis C virus infection in a large cohort of prisoners who have injected drugs

BACKGROUND

Hepatitis C virus (HCV) infection is common among prisoners, particularly those with a history of injecting drug use (IDU). Incarcerated people who inject drugs frequently report high-risk injecting practices both in prison and in the community. In spite of rising morbidity and mortality, utilisation of HCV-related services in Australia has been persistently low. This study aimed to describe the incidence, prevalence and correlates of HCV seropositivity in a large cohort of prisoners who have injected drugs, and to identify correlates of receiving confirmation of active infection.

METHODS

Data-linkage to a State-wide statutory notifiable diseases surveillance system was used to investigate the incidence of notified HCV seropositivity, seroconversion and confirmed HCV infection in a cohort of 735 prisoners with a history of IDU, over 14 years of follow up. Hepatitis C test results from prison medical records were used to identify correlates of testing positive in prison.

RESULTS

The crude incidence of HCV notification was 5.1 cases per 100 person-years. By the end of follow up, 55.1% of the cohort had been the subject of a HCV-related notification, and 47.4% of those tested in prison were HCV seropositive. In multivariable analyses, injecting in prison was strongly associated with HCV seropositivity, as was opioid use compared to injection of other drugs. The rate of reported diagnostic confirmation among those with notified infections was very low, at 6.6 confirmations per 100 seropositive participants per year.

CONCLUSIONS

Injecting drugs in prison was strongly associated with HCV seropositivity, highlighting the need for increased provision of services to mitigate the risk of transmission within prisons. Once identified as seropositive through screening, people with a history of IDU and incarceration may not be promptly receiving diagnostic services, which are necessary if they are to access treatment. Improving access to HCV-related services will be of particular importance in the coming years, as HCV-related morbidity and mortality is increasing, and next generation therapies are becoming more widely available.

A stepped wedge cluster randomized control trial of dried blood spot testing to improve the uptake of hepatitis C antibody testing within UK prisons

Background: The prevalence of hepatitis C (HCV) is elevated within prison populations, yet diagnosis in prisons remains low. Dried blood spot testing (DBST) is a simple procedure for the detection of HCV antibodies; its impact on testing in the prison context is unknown. Methods: We carried out a stepped-wedge cluster-randomized control trial of DBST for HCV among prisoners within five male prisons and one female prison. Each prison was a separate cluster. The order in which the intervention (training in use of DBST for HCV testing and logistic support) was introduced was randomized across clusters. The outcome measure was the HCV testing rate by prison. Imputation analysis was carried out to account for missing data. Planned and actual intervention times differed in some prisons; data were thus analysed by intention to treat (ITT) and by observed step times. Results: There was insufficient evidence of an effect of the intervention on testing rate using either the ITT intervention time (OR: 0.84; 95% CI: 0.68–1.03; P = 0.088) or using the actual intervention time (OR: 0.86; 95% CI: 0.71–1.06; P = 0.153). This was confirmed by the pooled results of five imputed data sets. Conclusions: DBST as a stand-alone intervention was insufficient to increase HCV diagnosis within the UK prison setting. Factors such as staff training and allocation of staff time for regular clinics are key to improving service delivery. We demonstrate that prisons can conduct rigorous studies of new interventions, but data collection can be problematic. Trial registration: International Standard Randomized Controlled Trial Number Register (ISRCTN number ISRCTN05628482).

Changes in HIV incidence among people who inject drugs in Taiwan following introduction of a harm reduction program: a study of two cohorts

BACKGROUND

Harm reduction strategies for combating HIV epidemics among people who inject drugs (PWID) have been implemented in several countries. However, large-scale studies using sensitive measurements of HIV incidence and intervention exposures in defined cohorts are rare. The aim of this study was to determine the association between harm reduction programs and HIV incidence among PWID.

METHODS AND FINDINGS

The study included two populations. For 3,851 PWID who entered prison between 2004 and 2010 and tested HIV positive upon incarceration, we tested their sera using a BED HIV-1 capture enzyme immunoassay to estimate HIV incidence. Also, we enrolled in a prospective study a cohort of 4,357 individuals who were released from prison via an amnesty on July 16, 2007. We followed them with interviews at intervals of 6-12 mo and by linking several databases. A total of 2,473 participants who were HIV negative in January 2006 had interviews between then and 2010 to evaluate the association between use of harm reduction programs and HIV incidence. We used survival methods with attendance at methadone clinics as a time-varying covariate to measure the association with HIV incidence. We used a Poisson regression model and calculated the HIV incidence rate to evaluate the association between needle/syringe program use and HIV incidence. Among the population of PWID who were imprisoned, the implementation of comprehensive harm reduction programs and a lower mean community HIV viral load were associated with a reduced HIV incidence among PWID. The HIV incidence in this population of PWID decreased from 18.2% in 2005 to 0.3% in 2010. In an individual-level analysis of the amnesty cohort, attendance at methadone clinics was associated with a significantly lower HIV incidence (adjusted hazard ratio: 0.20, 95% CI: 0.06-0.67), and frequent users of needle/syringe program services had lower HIV incidence (0% in high NSP users, 0.5% in non NSP users). In addition, no HIV seroconversions were detected among prison inmates.

CONCLUSIONS

Although our data are affected by participation bias, they strongly suggest that comprehensive harm- reduction services and free treatment were associated with reversal of a rapidly emerging epidemic of HIV among PWID. Please see later in the article for the Editors' Summary.

Prison and community outbreak of severe respiratory infection due to adenovirus type 14p1 in Tayside, UK

BACKGROUND

This report describes the investigation and public health management of a community-based outbreak of severe adenovirus serotype 14p1 respiratory infection affecting the Tayside area during 2011. It is the first report of an adenovirus outbreak involving prisons.

METHODS

An outbreak-based/incident management approach was carried out. Alerts were sent out to local doctors, general practitioners, prison healthcare staff and consultants so that cases could be identified prospectively. Sequencing of hexon, fibre and E1A regions of adenovirus were carried out to genotype the viruses.

RESULTS

Fifteen cases were identified in total, including 13 confirmed cases and 2 possible cases. There were 3 deaths amongst the 13 confirmed cases, with a case fatality rate of 23%. Eight of the cases had a direct association with one of the two prisons in the area.

CONCLUSIONS

We advise that surveillance measures for adenovirus infection and guidelines for the management of critically ill patients should be developed in order to identify outbreaks at an early stage and allow patients to receive appropriate treatment. Adenovirus infection should be borne in mind as a cause of severe pneumonia in closed settings such as prisons.

Cost-effectiveness of HCV case-finding for people who inject drugs via dried blood spot testing in specialist addiction services and prisons

OBJECTIVES

People who inject drugs (PWID) are at high risk for acquiring hepatitis C virus (HCV), but many are unaware of their infection. HCV dried blood spot (DBS) testing increases case-finding in addiction services and prisons. We determine the cost-effectiveness of increasing HCV case-finding among PWID by offering DBS testing in specialist addiction services or prisons as compared to using venepuncture.

DESIGN

Cost-utility analysis using a dynamic HCV transmission model among PWID, including: disease progression, diagnosis, treatment, injecting status, incarceration and addition services contact.

SETTING UK INTERVENTION

DBS testing in specialist addiction services or prisons. Intervention impact was determined by a meta-analysis of primary data.

PRIMARY AND SECONDARY OUTCOME MEASURES

Costs (in UK £, £1=US$1.60) and utilities (quality-adjusted life years, QALYs) were attached to each state and the incremental cost effectiveness ratio (ICER) determined. Multivariate uncertainty and one-way sensitivity analyses were performed.

RESULTS

For a £20 000 per QALY gained willingness-to-pay threshold, DBS testing in addiction services is cost-effective (ICER of £14 600 per QALY gained). Under the base-case assumption of no continuity of treatment/care when exiting/entering prison, DBS testing in prisons is not cost-effective (ICER of £59 400 per QALY gained). Results are robust to changes in HCV prevalence; increasing PWID treatment rates to those for ex-PWID considerably reduces ICER (£4500 and £30 000 per QALY gained for addiction services and prison, respectively). If continuity of care is >40%, the prison DBS ICER falls below £20 000 per QALY gained.

CONCLUSIONS

Despite low PWID treatment rates, increasing case-finding can be cost-effective in specialist addiction services, and in prisons if continuity of treatment/care is ensured.